By Julie Appleby - KHN
Mark Gottlieb's life changed in an instant when another driver collided with his car.
Four vertebrae in the upper part of his spine were damaged and six teeth were smashed.
In the months that followed that January 2019 accident, Gottlieb was fitted with dental crowns and, for the debilitating neck pain,
he underwent injections, chiropractic care and physical therapy.
The treatments were covered by your car insurance.
New Jersey law, like 12 other states, requires drivers to purchase personal injury protection coverage, or PIP, to pay for medical expenses.
Gottlieb was covered to the maximum: $ 250,000.
Unfortunately, Gottlieb's pain persisted.
"Nothing worked. The only option left was surgery," he said.
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Although Gottlieb wanted the operation to take place near his home, at the Bergen Pain Management clinic, where he was receiving treatment, they insisted that he go to Hudson Regional Hospital in Secaucus.
On April 3, 2020, Gottlieb underwent complex spinal fusion surgery.
He went home the same day.
Gottlieb's $ 250,000 personal injury protection from his Geico auto insurance ran out before the surgeon received full payment, potentially leaving him owing thousands of dollars.Erica Seryhm, KHN
His pain got a little better.
Then ... the bills came.
The Patient:
Mark Gottlieb, 59, a marketing consultant in Little Ferry, NJ, covered $ 250,000 in medical expenses by Geico auto insurance.
He also has an Aetna health insurance policy, which is secondary.
Medical service:
Anterior cervical discectomy and fusion, a type of neck surgery to replace damaged discs with bone grafts or implants to stabilize the spine.
Service Provider:
Hudson Regional Hospital, a private facility in Secaucus, NJ, and Bergen Pain Management in Paramus, NJ.
The total bill:
The hospital and the surgeon billed Gottlieb for more than $ 700,000.
The hospital billed $ 445,995 for the surgery, an amount reduced to $ 133,778 by Geico, who ultimately paid $ 103,354.
Bergen Pain Management billed an additional $ 264,444 for the lead surgeon.
Based on a review, Geico reduced it to $ 141,548.
He paid $ 52,365 until the Gottlieb medical coverage stated in his policy was exhausted.
The rest had to be paid by health insurance or by Gottlieb.
The Problem:
When injuries are the result of traffic accidents, auto insurance is primarily responsible for negotiating and paying medical bills.
That creates a number of financial traps for patients.
Gottlieb fell into all those traps.
Given how expensive treatments are often in the United States, accident victims can easily exceed policy limits, even generous personal injury coverage.
This leaves some people with huge bills on their hands.
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While it's rare to hear auto insurers complain that they have overpaid a hospital or doctor, "they tend to pay more for some of the same services" than health insurers, said Robert Passmore, vice president of American Property Casualty Insurance. Association.
This is partly because auto insurers often do not have extensive networks of medical providers who have agreed negotiated discounts on billed expenses, as health insurers do.
So patients end up "out of network,"
subject to whatever price the provider charges.
Gottlieb said he consulted Geico before his operation, but was told they had no information about health care networks.
With about $ 90,000 in his PIP fund at the time, he didn't worry.
He claimed that his efforts to obtain cost estimates were unsuccessful.
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Instead of network rates, auto insurers often use other payment calculations.
Some states set specific payments on rate schedules.
But not all medical billing codes are listed, and in those cases, they sometimes pay what the provider bills.
In this case, it was a lot.
Gottlieb's hospital and surgeon expenses, even after being reduced by Geico, were about eight times
what Medicare would have paid.
Although Geico typically pays state-set fees (which are drastically lower than what was charged), Gottlieb's bill included a bunch of billing codes that weren't on the state listing.
In most cases, the insurer paid exactly what was charged.
For example, Geico accepted the full price of $ 65,125 charged by the surgeon for the removal of a damaged disc and paid the hospital $ 39,195 for nine surgical screws.
In September, as bills from various providers kept coming in, Gottlieb's PIP fund dried up after the payment of $ 52,365 to Bergen Pain Management, down from the $ 141,548 that Geico had recommended as reimbursement for the surgeon.
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The insurance pays the bills as they are presented, which is often not in the order in which the treatment was provided.
"It appears that Bergen Pain Management is still owed $ 89,183 on the bill," Geico wrote in a September letter to Gottlieb, adding that he could submit that balance to his health insurer or pay it himself.
When you submitted the surgeon's bill to Aetna, you
discovered that neither the doctor nor the hospital were in your health plan's network.
He had not checked before the operation, as he never thought that outpatient surgery would exhaust the car policy.
That meant Aetna did not have a negotiated rate with its providers, which could have drastically reduced expenses.
Aetna told Gottlieb, in an email on Jan. 28, that it would allow an out-of-network payment of $ 4,051 for the surgeon.
In a written statement to KHN, Ethan Slavin, a spokesman for Aetna, said that amount was based on the terms of Gottlieb's insurance, which establishes payments to physicians of 10% above Medicare rates, for care outside of Medicare. network.
Mark Gottlieb's life changed after a devastating car accident.
She was left with broken teeth, four damaged vertebrae, and had to undergo surgery on her spine, resulting in medical bills that exhausted her auto insurance personal injury coverage.Erica Seryhm Lee, KHN
Since he had not yet met his annual out-of-network deductible, Gottlieb would have to pay the $ 4,051.
He withdrew his request for Aetna to pay.
Since out-of-network surgeons often demand payment of the rest of the bills from patients, Gottlieb is waiting to see if Bergen Pain Management - which has already received $ 52,365 for the operation - will claim more from him.
Neither the Bergen clinic nor the surgeon have claimed or sued him for the amount.
None responded to the multiple emails and phone calls made by KHN seeking comment.
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In a written statement, Hudson Regional spokesman Ron Simoncini said the hospital "charged the state-required rate" when applicable, and if there was no set price, "the charges were reasonable."
They did not claim additional payment.
Citing the privacy of policyholders, Geico declined to answer KHN's questions, including how to determine what to pay.
Did the auto insurer pay too much?
Geico had established a reimbursement of $ 141,548 for surgeon's fees.
"It's an outrageously high fee for this type of surgery," said Dr. Eeric Truumees, a professor at the University of Texas-Austin Dell School of Medicine.
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"I do a lot of cervical spine surgery and have never had such high fees, not even for a complex
10-hour
surgery
," said Truumees, president of the North American Spine Society.
He had no direct knowledge of the Gottlieb case.
In total, Geico recommended and partially paid nearly $ 245,000 to the hospital and surgeon for the procedure.
But Medicare would have paid about $ 29,500 for the entire procedure, of which about $ 1,800 would go to the surgeon and the rest to the hospital, according to Rand Corp. researchers who analyzed Gottlieb's bills at the request of KHN and NPR.
The surgeon's bill was also high compared to what private insurance typically pays, according to Barry Silver of Healthcare Horizons Consulting Group in Knoxville, Tennessee.
Silver compared Gottlieb's bills to hundreds of similar claims from two companies that administer employer health insurance across the country.
The total Geico paid to the hospital was in line with what the employers were paying and was actually less than the two highest fees seen in their data.
But the highest allowed charge in Silver's database for surgeon's fees was $ 87,549.
Much less than the $ 141,458 recommended by Geico.
Resolution:
Gottlieb remains unsure whether Bergen Pain Management will claim the remaining $ 89,000 from his bill.
Gottlieb sued the driver who caused the accident and obtained a significant "pain and suffering" settlement.
You want to save that money for future medical needs.
He has filed numerous complaints about his bills with state regulators, legislators, and his insurers.
Aetna sent your surgeon's bill to its internal Special Investigations Unit following your complaint.
But, "based on our investigation, we determined that there was no need to take action," said spokesman Slavin.
What to know:
Most people are not aware that car insurance is the first to activate after an accident and that it works very differently from health insurance, so you have to pay attention to the coordination of policies.
This is especially true if the accident requires significant treatment.
If your car policy has low coverage for personal injury, medical bills could shift to your health policy.
Therefore, when you receive a treatment that is not urgent;
Especially if it is exhaustive, such as a surgical intervention, it is important that you make sure that the providers belong to the network of your health insurer.
Some auto insurers have networks.
Ask if yours too.
Try to get a written cost estimate for non-urgent care and compare it to what is left of coverage in your auto policy.
"If it's more than you have left, you could negotiate with the hospital or doctor to lower your costs," explained Silver of Healthcare Horizons.
KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth journalism on health issues. Along with Policy Analysis and Surveys, KHN is one of KFF's top three programs. KFF is a nonprofit organization that provides health information to the nation.